ATI LPN
Skin Integrity NCLEX Questions Questions
Question 1 of 5
Tissue damage from burn injury activates an inflammatory response that increases the patient's risk for:
Correct Answer: C
Rationale: The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response(SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.
Question 2 of 5
The nurse notes that an older patient is malnourished and has minimal subcutaneous tissue. Which function of the subcutaneous tissue of the skin should the nurse consider as being potentially altered in this patient?
Correct Answer: A
Rationale: Subcutaneous tissue stores energy as fat, which is compromised in malnutrition.
Question 3 of 5
Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture?
Correct Answer: B
Rationale: Placing a pillow between the patient's legs when turning prevents adduction and supports the patient's legs. Administering analgesics addresses pain but does not directly protect bone remodeling and promote healing. Rotation of the affected leg can cause dislocation and must be avoided. Prone positioning does not need to be maintained at all times.
Question 4 of 5
The nurse is preparing information on the integumentary system for a group of high school students. Which layer of the skin should the nurse explain that plays an initial role in immunity?
Correct Answer: D
Rationale: The outermost layer of the epidermis serves as the first line of defense against pathogens, playing an initial role in immunity.
Question 5 of 5
The nurse suspects that a patient's disrupted skin integrity has a chemical basis. What could have caused this patient's health problem?
Correct Answer: A
Rationale: Urine can cause chemical irritation and skin breakdown.